Two factors necessary for the establishment of a pelvic infection are bacteria and a culture medium suitable for its growth. It has been demonstrated that despite the use of local and/or systemic antibiotics, virulent bacteria are present the operative site following hysterectomy. It has also been demonstrated at 10-200cc (average 40cc) of a fluid containing blood, serum, and necrotic debris, inevitably accumulates in the retroperitoneal space following either abdominal or vaginal hysterectomy. Furthermore, it has been shown that pathogenic bacteria can be cultured from this fluid in 62% of the cases. Thus, two major factors necessary for the establishment of a surgical infection, i.e., pathogenic bacteria and a suitable culture medium, are routinely present following either abdominal or vaginal hysterectomy. Considerable efforts are given to reducing the numbers of bacteria present at the operative site, e.g., local cleansing, application of antiseptic or antibiotic creams, suppositories, and douches, as well as the prophylactic administration of systemic antibiotics. However, less effort is expended in reducing the amount of culture medium available for bacterial growth. Suction drainage can effectively remove this fluid which normally collects in the retroperitoneal space following hysterectomy and also maintain collapse of this potential dead space. Routine removal of this fluid using this technique was associated with a significant reduction (p= &lt;0.01) in febrile morbidity from 26 to 11% for abdominal hysterectomy and from 32 to 8% for vaginal hysterectomy. The effectiveness of this technique has been confirmed.
The suction drainage tube utilized in this technique consists of a T-shaped drainage tube, a standard 200cc constant suction evacuator, and an appropriate connecting tube, specifically designed to effectively drain the surgical pedicles of the retroperitoneal space following hysterectomy.
An average 40cc (range 10-200cc) can suction from the pelvic retroperitoneal space following hysterectomy. The pelvic retroperitoneal space where this fluid collection routinely occurs is the space which remains following removal of the uterus. It is anatomically bordered by the bladder in front, the peritoneum forming the roof and back of the space, the sutured vaginal cuff forming the floor of the space, while the sutured pedicles and pelvic walls form the sides. In a subsequent study it has been demonstrated that this fluid is routinely contaminated with pathogenic bacteria. Effective removal of this bacteriologically contaminated fluid via T tube suction drainage is associated with a statistically significant reduction in pelvic infection and febrile morbidity following either abdominal or vaginal hysterectomy.
It is thought that this fluid collection represents a product of oozing of blood from raw surfaces, weeping of serum from the sutured pedicles, leaking of lymph from transected lymphatics, and dissolution of necrotic debris by enzymatic activity.
The drainage tube is specifically designed to effectively remove this fluid from the retroperitoneal space. The tube is T shaped so that the short cross arms reach laterally toward the pelvic walls and the sutured pedicles, while the long arm is brought out through the vagina so that it can be connected to suction. Each of the cross arms is typically 1and 1/2 inches long (approximately 4 centimeters). It has multiple drain ports of sufficient calibre that extend the entire length and circumference of the short cross arm such that the raw undersurface of the bladder in front, the raw surfaces of the bladder peritoneum above and behind, the sutured vaginal cuff and uterosacral ligaments below, the sutured pedicles of the round ligaments, utero-ovarian liaments, fallopian tubes, and raw surfaces of the broad ligaments laterally, will all be exposed to the multiple drain ports of the drainage tube and the aforementioned bacteriologically contaminated fluid will be suctioned away. A larger central drain port has been cut so that the two arms will easily fold up on one another when traction is applied on the long arm, thus facilitating an easy, painless, non-surgical removal.
The short cross arms of the T remain in the retroperitoneal space between the peritoneal closure and the vaginal closure while the long arm of the tube is brought out through the vagina. When connected to an evacuator connecting tube and thence to a suction evacuator, effective closed wound suction can be established in the retroperitoneal space.